The value of the initial post-EVAR computed tomography angiography scan in predicting future secondary procedures using the Powerlink stent graft.

J Vasc Surg. 2010 Jul 22;

Authors: Patel MS, Carpenter JP

OBJECTIVE: Current long-term surveillance after endovascular abdominal aortic aneurysm repair (EVAR) is based on high-resolution contrast-enhanced computed tomography (CT) scans at scheduled, lifelong intervals. The cancer and nephrotoxicity risks of interval CT scanning and prolonged radiation exposure are concerning. We sought to determine if surveillance CT angiography (CTA) can be safely reduced. METHODS: From July 2000 to November 2007, 345 patients were enrolled in U.S. Food and Drug Administration trials of the Powerlink System (Endologix, Irvine, Calif). An independent core laboratory analyzed 1519 post-EVAR CT scans (N = 1519) to 5 years to evaluate aneurysm size, migration, presence of endoleak, and evidence of graft obstruction. Analyses were conducted to determine the value of the initial CTA scan in predicting future secondary procedures in enrolled patients. RESULTS: At any time during follow-up, CTA identified endoleak in 123 patients (36%), with 95% of endoleaks being type II. In addition, 49 patients underwent 72 secondary procedures at a mean of 22 +/- 21 months (range, 2-2007 days) after initial EVAR. These were based on clinical identification of limb ischemia in 13 interventions (18%) or core laboratory identification of abnormal CT finding in 58 interventions (81%). Of the 58 core laboratory identified findings, the inciting abnormality was present on the initial postoperative scan in 49 (84%). Of the remaining nine CT-driven procedures, three (5.2%) were due to late sac expansion attributed to type II endoleak (n = 2) or endotension (n = 1); two (3.4%) were for prophylactic reasons in the absence of endoleak; and four (6.8%) were in patients with type II endoleak not observed by the core laboratory and without sac expansion. The negative predictive value of the initial postoperative CTA for the need for a secondary procedure is therefore 96.4%, which can be improved to 97.6% with duplex ultrasound surveillance to detect sac expansion. Thus, a negative initial postoperative CTA is highly predictive of long-term freedom from secondary intervention. CONCLUSIONS: Among enrolled patients with suitable anatomy for EVAR, most abnormalities that result in a secondary procedure are detected on the initial postoperative CTA or present with clinical symptoms. Long-term surveillance CTA may therefore be replaced by duplex ultrasound imaging if the initial postoperative CTA shows no abnormalities.

PMID: 20655690 [PubMed - as supplied by publisher]

Endoluminal treatment of type IA endoleak with Onyx.

J Vasc Surg. 2010 Jul 22;

Authors: Grisafi JL, Boiteau G, Detschelt E, Potts J, Kiproff P, Muluk SC

Type IA endoleaks associated with endovascular aortic aneurysm repair are typically treated with endovascular adjuncts. Technical failure results when such maneuvers are unsuccessful, and endograft removal may, unfortunately, become necessary. The novel management of a recalcitrant type IA endoleak using the artificial embolization device, Onyx (Micro Therapeutics Inc, Irvine, Calif) is presented for the case of a nonagenarian with prohibitive surgical risk after conventional techniques had failed.

PMID: 20655689 [PubMed - as supplied by publisher]

Discussion.

J Vasc Surg. 2010 Jul 22;

Authors:

PMID: 20655688 [PubMed - as supplied by publisher]

Atherosclerotic plaque composition assessed by virtual histology intravascular ultrasound and cerebral embolization after carotid stenting.

J Vasc Surg. 2010 Jul 22;

Authors: Timaran CH, Rosero EB, Martinez AE, Ilarraza A, Modrall JG, Clagett GP

OBJECTIVE: Previous studies have investigated the predictive value of clinical and morphologic parameters for distal embolization during carotid interventions. The composition of the atherosclerotic plaque, using virtual histology intravascular ultrasound (VH-IVUS) imaging obtained with an IVUS catheter that is advanced through the lesion after a filter has been placed distally, has not been evaluated as a marker for cerebral embolization. The purpose of this study was to assess the relationship between atherosclerotic plaque composition determined with VH-IVUS and the occurrence of cerebral embolization after carotid artery stenting (CAS). METHODS: During a 10-month period, 24 patients undergoing CAS procedures using a filter device for embolic protection were prospectively evaluated. All patients underwent VH-IVUS exams at the time of the intervention, transcranial Doppler (TCD) monitoring during CAS, and pre- and 24-hour postprocedural diffusion-weighted magnetic resonance imaging (DW-MRI) exams. Using VH-IVUS, plaque components were characterized as fibrotic, fibrofatty, dense calcium, and necrotic core. The frequency of Doppler-detected microembolic signals (MES) during CAS and the incidence and location of acute postprocedural embolic lesions detected with DW-MRI were assessed to determine cerebral embolization. Univariate and correlation analyses were used to assess the association between plaque composition and frequency of cerebral embolization. RESULTS: No periprocedural transient ischemic attacks, strokes, or deaths occurred within 30 days. Seventeen patients (71%) demonstrated new acute cerebral emboli in DW-MRI. Of these, all revealed ipsilateral lesions and 12 (50%) had contralateral lesions. For the entire study group, the median number of ipsilateral DW-MRI lesions was 1 (range, 0 to 3), and TCD MES counts were 227 (interquartile range, 143-315). Volumetric VH-IVUS analysis revealed that there was a trend for larger median dense calcium volume in patients with ipsilateral subclinical cerebral embolism detected with DW-MRI (33.2 +/- 24.5 mm(3) vs 11.4 +/- 6.1 mm(3); P = .08). Scatter plots of plaque components revealed statistically significant correlation between fibrofatty plaque volume (Spearman r = 0.49; P = .016) and number of new ipsilateral lesions in DW-MRI. Degree of cerebral embolization during CAS measured with TCD correlated with plaque burden, necrotic core, fibrofatty, and fibrous volumes. CONCLUSIONS: Plaque composition, as determined by VH-IVUS, only weakly correlates with the degree of cerebral embolization after carotid stenting. Specifically, there is a trend for larger dense calcium volume in patients with distal embolization. Of note, the proportion of necrotic core, which has traditionally been considered the main component of a vulnerable or unstable plaque, is not definitely associated with subclinical cerebral embolization after CAS when a filter device for embolic protection is used. The role of VH-IVUS in evaluating plaque composition during CAS remains unestablished and warrants further investigation.

PMID: 20655687 [PubMed - as supplied by publisher]

Glue embolus complicating the endovascular treatment of a patient with Loeys-Dietz syndrome.

J Vasc Surg. 2010 Jul 22;

Authors: Marine L, Gupta R, Gornik HL, Kashyap VS

A 43-year-old woman was diagnosed with Loeys-Dietz syndrome. Five months later, the patient presented with a symptomatic 2.6-cm subclavian pseudoaneurysm. Staged endovascular treatment was initiated with left vertebral artery embolization, followed by sac ablation and stent graft exclusion. The pseudoaneurysm cavity was filled with n-butylcyanoacrylate ("glue") via a microcatheter. Despite balloon occlusion of the pseudoaneurysm orifice, a small amount of glue debris embolized to the brachial artery, necessitating a vein bypass. In this case, distal embolization of glue may have been avoided by leaving a microcatheter in the aneurysm sac for glue injection after first deploying the stent graft.

PMID: 20655686 [PubMed - as supplied by publisher]

Mandibular subluxation stabilized by mouthpiece for distal internal carotid artery exposure in carotid endarterectomy.

J Vasc Surg. 2010 Jul 22;

Authors: Yoshino M, Fukumoto H, Mizutani T, Yuyama R, Hara T

The standard approach for carotid endarterectomy cannot provide adequate exposure of the distal internal carotid artery in the presence of high cervical carotid bifurcation or high plaque. Limited accessibility of the distal internal carotid artery has resulted in the development of various operative techniques. Mandibular subluxation is the most simple and least invasive technique, but it does require invasive maneuvers, such as wiring, to stabilize the mandible. We use a mouthpiece made by the dentist to stabilize the mandible in the physiologic subluxated position. This technique provides an adequate exposure of the distal internal carotid artery as with the other methods, and the risk of morbidity is very low.

PMID: 20655685 [PubMed - as supplied by publisher]

Early side effects after embolization of a carotid body tumor using Onyx.

J Vasc Surg. 2010 Jul 22;

Authors: Wiegand S, Kureck I, Chapot R, Sesterhenn AM, Bien S, Werner JA

The case of a 20-year-old woman with a carotid body tumor of Shamblin class III is reported. Ten hours after preoperative direct intralesional embolization with 20 mL Onyx (ethylene-vinyl alcohol copolymer; Micro Therapeutics, Irvine, Calif), the patient showed symptoms of Horner syndrome and deficits of the hypoglossal and glossopharyngeal nerves. Intraoperative examination 12 hours after Onyx embolization revealed a massive swelling of the hypoglossal and glossopharyngeal nerves. The patient's tongue motility and glossopharyngeal function improved after surgery, but Horner syndrome was still present. Owing to the delayed occurrence of these adverse effects, the optimal time of surgical intervention after Onyx embolization should be discussed and perhaps expedited.

PMID: 20655684 [PubMed - as supplied by publisher]

A contemporary rural trauma center experience in blunt traumatic aortic injury.

J Vasc Surg. 2010 Jul 22;

Authors: Durham CA, McNally MM, Parker FM, Bogey WM, Powell CS, Goettler CE, Rotondo MF, Stoner MC

INTRODUCTION: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair. The purpose of this study is to review a rural trauma center experience with TAI. METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Clinical, anatomical, and procedural variables of all cases were systematically reviewed. Clinical endpoints included mortality, and aortic-related mortality, and hospital length of stay. The study population was stratified by those that underwent surgical repair (SR) and those managed medically (MM). RESULTS: Fifty-six patients presented with blunt TAI; 35 patients (62.5%) were surgically repaired (22 open, 13 TEVAR), while 21 (37.5%) were MM. The only difference in comorbidities was a higher rate of coronary artery disease in MM. Mean hospital arrival time (SR, 188.6 +/- 30.3 minutes, MM, 253 +/- 65.3 minutes), aortic injury grade (SR, 2.7 +/- 0.1; MM, 2.3 +/- 0.2), and injury severity score were not significantly different between the groups. Head Abbreviated Injury Score (AIS) was worse in the MM group, while chest AIS was worse in the SR group (P < .05). There were nine (42.9%) deaths in the MM group, while there were only two (5.7%) in the SR group (P < .001). There was no significant difference in aortic-related mortality. Mean follow-up time was not statistically different. CONCLUSION: These data provide a group of stable patients to examine the management of TAI in the endovascular era. The low aortic-related mortality in the MM group demonstrates that there is time for a thorough evaluation in patients sustaining TAI who arrive without hemodynamic instability.

PMID: 20655683 [PubMed - as supplied by publisher]

Classification of proximal endovenous closure levels and treatment algorithm.

J Vasc Surg. 2010 Jun 18;

Authors: Lawrence PF, Chandra A, Wu M, Rigberg D, Derubertis B, Gelabert H, Jimenez JC, Carter V

OBJECTIVES: Endovenous closure is a common method to treat saphenous vein incompetence. Despite attempts to prevent it, some patients have extension of thrombus above the ideal site of closure immediately below the epigastric vein. We have developed a classification system for the level of saphenous vein closure to guide further therapy after endovenous treatment. METHODS: A six-tier classification system was developed, based on thrombus proximity to the epigastric or femoral vein, and an algorithm for treatment, based on level of closure was applied to all patients. RESULTS: Five hundred consecutive patients underwent radio-frequency ablation of the saphenous vein; it was successfully closed in 498 (99.6%) patients. Thirteen patients (2.6%) experienced thrombus bulging into the femoral vein or adherent to its wall, which was treated with anticoagulation. All of these patients had thrombus retraction to the level of the saphenofemoral junction (SFJ) in an average of 16 days with concurrent anticoagulation. No femoral deep venous thrombosis (DVT) occurred in the series. There was a significantly higher rate of proximal thrombus extension in those patients with a history of DVT and those with a great saphenous vein (GSV) diameter of >8 mm (P < .02). CONCLUSIONS: A classification system for saphenous endovenous closure which extends above the epigastric vein has been helpful in guiding management. A GSV diameter at the SFJ of >8 mm and a history of DVT results in significantly higher rates of proximal thrombus extension into the femoral vein. A short course of LMWH, until clot retracts back into the saphenous vein, is therapeutic. Management of the patients with thrombus flush with the femoral vein wall still needs to be defined, but the outcome from these patients is generally benign.

PMID: 20646894 [PubMed - as supplied by publisher]

Discussion.

J Vasc Surg. 2010 Jun 18;

Authors:

PMID: 20646893 [PubMed - as supplied by publisher]

A randomized, controlled trial of endovenous thermal ablation using the 810-nm wavelength laser and the ClosurePLUS radiofrequency ablation methods for superficial venous insufficiency of the great saphenous vein.

J Vasc Surg. 2010 Jul 15;

Authors: Gale SS, Lee JN, Walsh ME, Wojnarowski DL, Comerota AJ

BACKGROUND: Great saphenous vein (GSV) incompetence is the most common cause of superficial venous insufficiency. Radiofrequency catheter ablation (RFA) is superior to conventional ligation and stripping, and endovenous laser treatment (EVL) has emerged as an effective alternative to RFA. This randomized study evaluated RFA and EVL for superficial venous insufficiency due to GSV incompetence and compared early and 1-year results. METHODS: Between June 2006 and May 2008, patients with symptomatic primary venous insufficiency due to GSV incompetence were randomized to RFA or EVL. Patients with bilateral disease were randomized for treatment of the first leg and received the alternative method on the other. Pretreatment examination included a leg assessment using the Venous Clinical Severity Score (VCSS) and CEAP classification. Patients completed the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2). RFA was performed with the ClosurePlus system (VNUS Medical Technologies, Sunnyvale, Calif). EVL was performed with the EVLT system (AngioDynamics Inc, Queensbury, NY). Early (1-week and 1-month) postoperative results of pain, bruising, erythema, and hematoma were recorded. Duplex ultrasound (DU) imaging was used at 1 week and 1 year to evaluate vein status. VCSS scores and CEAP clinical class were recorded at each postoperative visit, and quality of life (QOL) using CIVIQ2 was assessed at 1 month and 1 year. RESULTS: The study enrolled 118 patients (141 limbs): 46 (39%) were randomized to RFA and 48 (40%) to EVL, and 24 (20%) had bilateral GSV incompetence. At 1 week, one patient in the RFA group had an open GSV and was deemed a failure. More bruising occurred in the EVL group (P = .01) at 1 week, but at 1 month, there was no difference in bruising between groups. At 1 year, DU imaging showed evidence of recanalization with reflux in 11 RFA and 2 EVL patients (P = .002). The mean VCSS score change from baseline to 1 week postprocedure was higher for RFA than EVL (P = .002), but there was no difference between groups at 1 month (P = .07) and 1 year (P = .9). Overall QOL mean score improved over time for all patients (P < .001). CEAP clinical class scores of >/=3 were recorded in 21 RFA (44%) and 24 EVL patients (44%) pretreatment, but at 1-year, 9 RFA (19%) and 12 EVL patients (24%) had scores of >/=3 (P < .001). This represented a significant improvement in all patients compared with baseline. CONCLUSION: Both methods of endovenous ablation effectively reduce symptoms of superficial venous insufficiency. EVL is associated with greater bruising and discomfort in the perioperative period but may provide a more secure closure over the long-term than RFA.

PMID: 20638231 [PubMed - as supplied by publisher]

Significant sac retraction after endovascular aneurysm repair is a robust indicator of durable treatment success.

J Vasc Surg. 2010 Jul 15;

Authors: Houbballah R, Majewski M, Becquemin JP

OBJECTIVES: The principal aim of this study was to demonstrate that significant sac retraction (SSR) was a predictive marker of durable success after endovascular aortic repair (EVAR). If verified, follow-up (FU) of patients with SSR may become unnecessary. In addition, the clinical features of the patients and aneurysms were analyzed to identify predictive factors of SSR. METHODS: A group of 371 patients treated by EVAR had a complete clinical exam, computed tomography (CT) scan, and duplex scan follow-up. Data were collected prospectively and analyzed retrospectively. We assessed the difference between the largest diameter of the aneurysm (D) and the diameter of the stent-graft body (D1) on each postoperative CT scan. SSR was defined as a minimum of 75% reduction of this difference between the first and any of the following CT scans. Treatment success was defined as survival free of aneurysm-related death, type I or III endoleak, aneurysm expansion exceeding 5 mm, rupture, surgical conversion, migration, and graft occlusion. To assess the predictive factors of SSR, we performed a multivariable analysis and a logistic regression of the most significant variables. RESULTS: SSR was observed in 24.8% (92/371) of the patients after an average of 26 +/- 21 months of FU. The mean duration of FU in this group was 50 +/- 26 months (vs 45 +/- 25 months; P = NS). Survival was significantly longer in the SSR group (96 +/- 3 months vs 93 +/- 3 months; P < .05). No rupture, surgical, or endovascular conversion was reported in the SSR group. The frequency of type I (2.2% vs 15.4%; P < .001), type II (3.3% vs 29.4%; P < 10(-6)), and secondary interventions (3.3% vs 13.3%;P < .05) was lower in the SSR group. All type I and III endoleaks were diagnosed and treated before SSR detection. Since SSR was detected, treatment success remained until last follow-up in 98.9% (91 of 92) of the patients. The independent predictive factors of SSR were abdominal aortic aneurysm (AAA) diameter <55 mm (odds ratio [OR] 3.91; 95% confidence interval [CI]: 2.16-7.11), infra renal aorta diameter <23 mm (OR 2.96; 95% CI: 1.74-5.03), and a proximal neck length >22 mm (OR 2.41; 95% CI: 1.42-4.10). CONCLUSION: In this series, SSR was accurately predictive of a durable success after EVAR. It occurred mostly in patients with a favorable anatomy. Less intensive follow-up work up seems to be safe in patients with SSR.

PMID: 20638230 [PubMed - as supplied by publisher]

The history of the in situ saphenous vein bypass.

J Vasc Surg. 2010 Jul 15;

Authors: Connolly JE

PMID: 20638229 [PubMed - as supplied by publisher]

Prognostic values of C-reactive protein levels on clinical outcome after endovascular therapy in hemodialysis patients with peripheral artery disease.

J Vasc Surg. 2010 Jul 15;

Authors: Ishii H, Kumada Y, Toriyama T, Aoyama T, Takahashi H, Murohara T

PURPOSE: Endovascular therapy (EVT) has been widely performed for peripheral artery disease. However, the high restenosis rate after EVT remains a major problem in patients on hemodialysis. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse events. We evaluated the possible prognostic values of CRP on outcomes in hemodialysis patients undergoing EVT. METHODS: A total of 234 hemodialysis patients undergoing EVT for peripheral artery disease were enrolled and followed-up for up to 5 years. They were divided into tertiles according to serum CRP levels (lowest tertile, <1.4 mg/L; middle tertile, 1.4-6.0 mg/L; highest tertile, >/=6.0 mg/L). We analyzed the incidence of any reintervention or above-ankle amputation of the limb index (RAO) and any-cause death. RESULTS: Kaplan-Meier analysis showed that the event-free rate from the composite end point of RAO and any-cause death for 5 years was 60.2% in the lowest tertile, 50.0% in the middle tertile, and 25.1% in the highest tertile (P < .0001). The survival rate from any-cause death for 5 years was 81.5% in the lowest tertile, 65.2% in the middle tertile, and 59.3% in the highest tertile (P =.0078). Even after adjusting for other risk factors at baseline, preprocedural CRP levels were a significant predictive factor for RAO and any-cause death after EVT in a multivariable Cox analysis. CONCLUSIONS: Elevated preprocedural serum CRP levels were associated with RAO and any-cause death after EVT in hemodialysis patients with peripheral artery disease.

PMID: 20638228 [PubMed - as supplied by publisher]

Mechanisms to explain the poor results of carotid artery stenting (CAS) in symptomatic patients to date and options to improve CAS outcomes.

J Vasc Surg. 2010 Jul 15;

Authors: Paraskevas KI, Mikhailidis DP, Veith FJ

BACKGROUND: Carotid artery stenting (CAS) is considered by many as an alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. However, recent trials demonstrated inferior results for CAS in symptomatic patients compared with CEA. We reviewed the literature to evaluate the appropriateness of CAS for symptomatic carotid artery stenosis and to determine the pathogenetic mechanism(s) associated with stroke following the treatment of such lesions. Based on this, we propose steps to improve the results of CAS for the treatment of symptomatic carotid stenosis. METHODS: PubMed/Medline was searched up to March 25, 2010 for studies investigating the efficacy of CAS for the management of symptomatic carotid stenosis. Search terms used were "carotid artery stenting," "symptomatic carotid artery stenosis," "carotid endarterectomy," "stroke," "recurrent carotid stenosis," and "long-term results" in various combinations. RESULTS: Current data suggest that CAS is not equivalent to CEA for the treatment of symptomatic carotid stenosis. Differences in carotid plaque morphology and a higher incidence of microemboli and cerebrovascular events during and after CAS compared with CEA may account for these inferior results. CONCLUSIONS: Currently, most symptomatic patients are inappropriate candidates for CAS. Improved CAS technology referable to stent design and embolic protection strategies may alter this conclusion in the future.

PMID: 20638227 [PubMed - as supplied by publisher]

Mechanosensitive transient receptor potential vanilloid type 1 channels contribute to vascular remodeling of rat fistula veins.

J Vasc Surg. 2010 Jul 15;

Authors: Chen YS, Lu MJ, Huang HS, Ma MC

OBJECTIVE: We previously showed that matrix metalloproteinases (MMPs) contribute to tremendous blood flow-induced venous wall thickening during the maturation of an arteriovenous fistula (AVF). However, how veins in the fistula sense a dramatic change in the blood flow remains unknown. Because mechanosensitive transient receptor potential vanilloid channels (TRPVs) are present in the endothelium, we examined whether the Ca(2+)-permeable TRPVs play a role in remodeling of fistula veins. METHODS: The fistula veins were generated at femoral AVF of Wistar rats. Changes in the hemodynamics and the width and internal radius of the iliac vein were studied at 3, 7, 14, and 28 days, then the iliac vein was removed and examined for changes in wall thickness and protein or mRNA expression by immunofluorecent stain, Western blot, or real time PCR. Changes in MMP2 activity was examined by gelatin zymography. Two ligatures were performed in iliac vein to prevent venodilatation to confirm the effect of dramatic changes in hemodynamics on TRPV expression. The specific role of TRPV was studied in another group of fistula veins given with capsazepine via a subcutaneous mini-osmotic pump for 28 days. RESULTS: The fistula veins demonstrated high flow/wall shear stress (WSS), wall thickening, and venodilatation compared with control veins. The WSS increase was positively correlated with upregulation of TRPV1, but not TRPV4. Narrowing fistula veins prevented TRPV1 upregulation, indicating that high flow directly upregulates TRPV1. We examined the underlying signaling components and found that enhanced Ca(2+)/calmodulin-dependent protein kinase II (CaMK II) activity upregulated endothelial nitric oxide synthase (eNOS) and downregulated arginase I in the fistula veins. These changes were reversed by a CaMK II inhibitor. The relative levels of eNOS and arginase I activity consequently augmented NO formation, which coincided with an increase in MMP2 activity. Chronic inhibition of TRPV1 in the fistula veins by capsazepine showed no effect on high flow and TRPV1 expression, but markedly attenuated WSS, which was concomitantly associated with attenuation of CaMK II activity, NO-dependent MMP2 activation, and remodeling. CONCLUSION: These findings indicate that TRPV1 is essential in the remodeling of AVFs and that WSS leads to TRPV1 upregulation, which then enhances remodeling, therefore, inhibition of TRPV1 pathway may prolong the lifespan of an AVF by decreasing WSS and vein wall remodeling.

PMID: 20638226 [PubMed - as supplied by publisher]

Venous ulcers in primary chronic venous insufficiency: prevention and treatment.

J Vasc Surg. 2010 Jul 15;

Authors: Neglen P,

PMID: 20638225 [PubMed - as supplied by publisher]

Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux.

J Vasc Surg. 2010 Jul 15;

Authors: Bradbury AW, Bate G, Pang K, Darvall KA, Adam DJ

OBJECTIVE: To test the hypothesis that ultrasound-guided foam sclerotherapy (UGFS) is a safe and durable treatment for superficial venous reflux (SVR) associated with CEAP clinical grade 2-6 disease. METHODS: This was an interrogation of a prospectively gathered computerized database. RESULTS: Between March 23, 2004 and December 31, 2009, 977 patients (1252 legs) underwent UGFS for unilateral (702 legs) or bilateral (550 legs) SVR in association with CEAP clinical grade 2-3 (n = 868), 4 (n = 232), or 5/6 (n = 152) disease. The following reflux in 1417 venous segments was treated: primary great saphenous vein (GSV) (n = 745); recurrent GSV (n = 286), primary small saphenous vein (SSV) (n = 189), recurrent SSV (n = 50); primary anterior accessory saphenous vein (AASV) (n = 93); recurrent AASV (n = 46); vein of the popliteal fossa (VOPF) (n = 5), and Giacomini vein (GV) (n = 3). Three hundred forty-eight legs (27.8%) had undergone previous surgery. Three patients suffered post-UGFS deep vein thrombosis (DVT) and one a pulmonary embolus (PE), all within the first month (0.4% venous thrombo-embolic complication rate). Five patients (0.5%) had transient visual disturbance at the time of, or shortly after, treatment. No other neurologic or serious complications were reported. During a mean (range) follow-up of 28 (<1 to 68) months, 161 (12.9%) legs underwent a further session of UGFS for truncal VV at a mean (range) of 17 (<1 to 63) months following the first treatment. In 52 legs, retreatment was due to the development of new SVR and in 109 legs was for true recurrence (8.7% complete or partial recanalization rate leading to treatment). There was no significant difference in retreatment rates between UGFS for GSV and SSV reflux or between UGFS for primary or recurrent disease. CONCLUSION: UGFS for CEAP 2-6 SVR is associated with a low complication and retreatment rate. However, as patients are at risk of developing recurrent and new SVR they should be kept under review. Further UGFS for new or recurrent disease is simple, safe, and effective.

PMID: 20638224 [PubMed - as supplied by publisher]

A meta-analysis of clinical studies of statins for prevention of abdominal aortic aneurysm expansion.

J Vasc Surg. 2010 Jul 15;

Authors: Takagi H, Matsui M, Umemoto T

BACKGROUND: Despite the absence of a relationship between cholesterol and abdominal aortic aneurysm (AAA) expansion, there is evidence from a number of studies to suggest that statin therapy may influence AAA expansion, presumably through pleiotropic effects. To confirm whether statin therapy is associated with less AAA expansion, we performed a meta-analysis of clinical controlled studies of statin therapy for prevention of AAA expansion. METHODS: To identify all clinical studies of statin therapy vs control (no statins) enrolling patients with small (</=55 mm) AAA, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched. For each study, data regarding AAA expansion in both the statin and control groups were used to generate standardized mean differences (SMDs; <0 favoring statin therapy; >0 favoring control) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted averages of logarithmic SMDs in fixed-effects and random-effects models. RESULTS: We identified five clinical controlled studies of statin therapy vs control enrolling patients with small AAA, including no randomized and five observational studies. Our meta-analysis included data on 697 patients with small AAA received statin therapy or no statins. Pooled analysis demonstrated that statin therapy was statistically significantly associated with less expansion rates (random-effects SMD, -0.50; 95% CI, -0.75 to -0.25; P = .0001). There was statistically significant trial heterogeneity of results (P = .03). Exclusion of any single trial from the analysis did not substantively alter the overall result of our analysis. There was no evidence of significant publication bias (P = .81). CONCLUSION: Statin therapy is associated with less expansion rates in patients with small AAA. To confirm our and more accurately assess the effect of statins on AA expansion, a large randomized trial is needed.

PMID: 20638223 [PubMed - as supplied by publisher]

Complex subclavian artery pseudoaneurysm causing failure of endovascular stent repair with salvage by percutaneous thrombin injection.

J Vasc Surg. 2010 Jul 15;

Authors: Lee GS, Brawley J, Hung R

We report a case of traumatic right subclavian artery pseudoaneurysm, which failed initial treatment by endovascular covered stent. Subsequent catheter angiogram demonstrated filling of the pseudoaneurysm from retrograde flow of the right vertebral artery with outflow through the internal mammary artery. With access to the pseudoaneruysm obstructed, percutaneous thrombin injection was performed. The complex connections of the pseudoaneurysm to the right subclavian, vertebral, and internal mammary arteries resulted in the initial failure of the covered stent to induce thrombosis because of inflow from the right vertebral artery, a so-called "back door vessel".

PMID: 20638222 [PubMed - as supplied by publisher]